Normally, the direction of urine produced in the kidneys should always be downwards (from the kidneys to the bladder). Both during urination and during storage of urine in the bladder, there should be no return of urine towards the ureter and kidney, which are the upper urinary system. Vesicoureteral reflux (VUR) is urine leakage from the bladder to the kidneys. It is also known as kidney reflux among the public.
There should be no upward passage of urine from the bladder. This is provided by the anti-reflux mechanism created by the connection of the ureter to the bladder (detrusor muscle of the bladder, Valdeyer's sheath). In children with congenital defects in this mechanism, urine refluxes slightly upwards instead of being completely evacuated, causing infections in the upper urinary tract, the kidney, and chronic kidney damage in the medium-long term.
The frequency of VUR in the normal population is 1%. This rate is 30% in children with recurrent urinary tract infections. In newborns whose kidney enlargement (antenatal hydronephrosis) is detected on ultrasonography in the womb; While the frequency of VUR is 15% in those with no abnormality detected in postnatal ultrasonography, this rate is around 35% in those with any abnormality detected.
While the probability of having VUR in siblings of children with VUR is 35%; VUR is detected in 100% of identical twins.
Symptoms usually begin in childhood. Febrile diseases before infancy and adolescence may occur due to urinary tract infections due to vesicoureteral reflux (VUR). Restlessness in infancy, malnutrition, and inadequate growth may also be caused by kidney reflux. Older children may also describe pain when urinating and color changes in the urine. Parents may also notice foul-smelling urine.
The most important symptom of renal reflux in children is urinary tract infection. In case of recurrent urinary tract infection or if the bacteria that caused the first febrile urinary tract infection are detected atypically in the urine culture (other than e.coli),vesicoureteral reflux (VUR) investigation is required.
Although ultrasonography is considered the first imaging method in children with suspected VUR, contrast-enhanced radiographs showing leakage from the bladder to the kidney, called voiding cystourethrography, are required for definitive diagnosis. DMSA scintigraphy is also used to evaluate the damage caused by VUR disease in the kidneys.
For neurogenic bladder disorders that may cause renal reflux, it may be necessary to resort to diagnostic methods such as uroflowmetry, urodynamics, and lumbosacral MRI.
In children with urinary tract infection, the first imaging method to be performed to investigate the cause is ultrasonography. It has taken the first place because it does not create any radiation, is not an invasive procedure, and is easily accessible. However, when findings related to vesicoureteral reflux are detected in this ultrasonography or when urinary tract infection recurs more than once, an x-ray called voiding cystourethrography is required for the definitive diagnosis of renal reflux.
A catheter is placed in the urinary tract of the individual to whom voiding will be performed. Then, the bladder is filled with medicated water, which we call contrast, through this catheter. While the bladder is filling, various x-rays are taken to see whether there is leakage from the bladder upward (to the ureter and kidney). The same x-ray procedure is performed when the catheter is removed and the patient urinates. Thus, this radiological film is completed.
Voiding cystourethrography film, which is performed by placing a catheter into the bladder, is not a harmful imaging. Since the given contrast material is not released into the systemic circulation, side effects related to the contrast material do not occur. It does not harm children's urinary tract. Contrary to popular belief, it does not harm the vaginal area of girls. Because even though the urinary outlet and the vaginal area are adjacent, they are different. It is also essential for definitive diagnosis in children with suspected vesicoureteral reflux. The most important point to consider is to treat the existing active infection by performing a urine culture beforehand.
Voiding cystourethrography film used for the diagnosis of vesicoureteral reflux is taken with modern devices at Bursa Doruk Nilüfer Hospital.
Many factors must be considered when discussing treatment options for vesicoureteral reflux (VUR). The decision is made by considering parameters such as the degree of reflux, the frequency and severity of urinary tract infections, whether the child has developmental delays, whether kidney damage has developed, the age of the patient, and the socioeconomic status of the family.
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The main goal is to avoid the risks and trauma of surgery in children with low grades, no disruption to follow-up, spontaneous recovery possible, and no obvious symptoms.
It is the long-term administration of low doses of prophylactic antibiotics to prevent urinary tract infection. Thus, low-grade reflux is given the opportunity to heal spontaneously.
The child should be encouraged to go to the toilet and urinate at regular intervals at home and at school. The child must sit in the appropriate position on the toilet to completely empty the bladder and bowels. Fluid intake should be spread evenly throughout the day. Children with constipation problems must be treated. With these simple precautions, the possibility of urinary tract infection can be reduced and the damage caused by kidney reflux can be prevented.
Some scientific studies have found that circumcision may have a protective effect by reducing urinary tract infections in boys with vesicoureteral reflux.
Corrective intervention for vesicoureteral reflux should be considered in low- or high-grade reflux cases with ongoing urinary tract infection despite antibiotic prophylaxis, and in some patients directly in high-grade reflux cases, and in children who have reached puberty and in whom an increase in renal loss areas is detected. These surgical procedures are generally divided into two: endoscopic and open (performed through an incision). Which method to choose is decided according to some factors related to the patient (degree of reflux, presence of previous unsuccessful procedures).
A thin camera (cystoscope) is entered through the urinary tract and filling material is injected into the mouth of the urinary tract where leakage occurs. Thus, an attempt is made to eliminate the insufficiency at the mouth of the channel where the reflux occurs. It is a daily procedure and can be applied in a short time. In some cases, the process may need to be repeated several times. The success rate goes up to 85% in repeated applications. It is especially successful in low-grade reflux cases.
It is the most successful treatment method. It is an important option in those with a history of unsuccessful injection (endoscopic procedure),in patients with high-grade VUR, and in cases where VUR is accompanied by other anatomical disorders. There are many reported surgical techniques and success rates are around 98%. This surgery can be performed open, laparoscopic and robotically. They have no obvious superiority over each other. The decision should be made according to the age of the patient, the experience of the surgeon and the technical facilities of the hospital.
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